This is a hard story. I am writing it because it’s important. A warning: a parakeet dies in this story — badly. I’m telling it so parakeets don’t die badly anymore. If you’re sensitive to this, just read up on the ethics of inaction; they are well described in other literature.

Yeah, it was a blue parakeet. I still can’t look at photos of parakeets easily.

Friendship and the ethics of inaction

I’m writing this story because I had a real fight, with a real friend, last year. I had a child sex trafficking case and chose to report it despite significant personal risk. It was scary. I was scared, and I called my friend when I was really afraid. I had been shaking for about two hours and couldn’t beat the fear. So I called a friend. And that’s how my friend knew about it.

In fact, I called a lot of friends during that period. A lot of responsible adults who had been a support network for me for years.

And half of them said not to report. They said I was too important to risk my life on a report like that. That they wouldn’t. They wouldn’t report and sometimes it wasn’t worth it.

And half of them said, of course you reported. There is literally nothing else you could have done. And it sucks, and we’re here for you.

One friend was really mad at me. They said they really didn’t believe that anyone is ever responsible for things they chose not to do. Inaction, they said, means no accountability. And they said I had other responsibilities and I couldn’t put my life at risk over something that wasn’t my problem. And that was a real disagreement, and I really lost a relationship over it.

Because I refused. Or rather, I chose not to share that position. And I don’t need people in my intimate space who truly hold it. It’s hard enough as it is to act; having people around you who tell you not to, or don’t help, is just too difficult.

The research on defiance and nonconformity runs roughly 35% → 9% → under 0.5%, as the cost of holding the line moves from awkwardness to death.

So I lost half of my friends over this, people I really like and respect in other ways, over this decision. We can still be friends, but we’re not intimate friends. And there is a difference, and it does suck. But life is long, and relationships evolve, and we’ll see what happens.

It’s just what happened for me at this age.

• The Golden State — John Doe

Why do I believe in the ethics of inaction?

I could call on my formal medical training for this. They hit doctors hard for this in training. Formally, in most programs with ethicists, but also in training when things happen. And if you don’t get tagged for it formally and it doesn’t get through, you handle far too many cases for something not to teach you hard if you have empathy about the things you “should have done”.

There is actually a lot of grief when in a position of power over other people, like a clinician. And most empathetic people privately agonize about decisions made under uncertainty that later become clearer, and you wonder if you made the right call and have to find a way to internally cope with that.

Some of us harden, try to shut the empathy off. Others explore it a lot and learn how and when to take responsibility. How to cope with misakes.

Uncertainty and rapid decision-making come into play in emergency services. I’ve had discussions about this with international development folks, ER docs, paramedics, wildland firefighters, special forces, and sailboat captains. All of these fields require experienced rapid decision-makers.

You get good at it when there are real stakes. Your empathy forces you to; your profession holds you accountable. Reality bites. Some get depressed; some leave.

It sounds cool and smart. But you need to know where it came from. Doing this professionally is just how I practice the skill now. It’s definitely not where I learned it.

I learned it from the parakeet.

• Trendsetter — Connor Price & Haviah Mighty

What happened to the parakeet?

My family wasn’t functional. First. I need to say that so you know I was young, in a really toxic system. Bowen’s family theory is really helpful for toxic systems, and I highly recommend it, not only for families but for toxic workplaces. I was the Hero in this system. Basically assigned the role of being responsible for achieving and justifying the system.

So briefly, I was 12 and the oldest child. There were 6 children in the house at that time. I was a parentified child and had the care of two extra children under 5 that we did daycare for. So, not a great situation. Probably we moved to another state later that year because of child services reports, but as a child you don’t really understand things like that.

A relative came to the house and left a parakeet. The relative correctly interpreted the system as toxic, but their intervention was to leave a very cute, very well-trained, and very elaborately accessorized parakeet with my sister, who was 10 and two years younger than I was. She had the assigned role of the Angel in the system, responsible for nothing but being beloved by everyone.

I was probably a very controlling little kid, and an outsider might not have understood why, so they were probably just trying to restore balance. But the end result is I was forbidden to have anything to do with the parakeet. The parakeet was only my sister’s to feed and care for, and she got special 1:1 training and special treatment and the special role of ‘parakeet owner’.

The relative was asked to leave, and there we were. Me at 12 — the actual caregiver in the household, my sister at 10 — just kind of a normal, if a bit underaccountable, kid, and the unfortunate parakeet. Let’s leave my parents out of this. They were morally accountable too, but that’s another story. In this story, they didn’t take care of anyone and were often out of the house. Who cares why. It just was.

This is about me and the parakeet.

So for a few months my sister did look after the parakeet. Then she lost interest, and the less appealing tasks started falling to me. So for a while I was allowed to clean the cage but not do the feeding. Then I was allowed to refill the water, but not go to the pet store.

Then she stopped doing anything. And the daily ritual of opening up the cage cover and other things just didn’t happen. Or I’d have to yell at her to do it because I wasn’t allowed to. And she got more and more grudging about me telling her what to do.

Like normal siblings, but not in a normal situation.

So this part is important: I was pissed.

I was 12. I wasn’t that mature, and I had been treated unjustly. Not only did I have to clean up the shit, but I didn’t get to go to the pet store, and I wasn’t allowed to take the parakeet out and let it walk around and actually play with it. All the fun stuff went to my sister, and all the actual work fell to me. So I was pissed.

And one day I just refused to do anything. I said fuck it, the parakeet is not my problem. These people are jerks; it’s their parakeet, fine. They can take care of it. And I mentally crossed my arms and just did NOTHING.

So there is the cage, the cover on, and there is chirping and indignant flapping from within the cage, and I just walked by the cage. I don’t remember for how long. But I remember at least two times quite clearly that I did that.

I didn’t open the cover. I didn’t tell my sister. I just did…

Nothing.

And when I finally opened the cage later, it was too late. The parakeet had starved in a house full of people. And I was the one who had to take the starved bird’s body from under the cover, the henpecked cage. I made a matchbox casket, and I buried the bird.

I wish I could say I consoled my sister, but I don’t think I did. I was horribly, horribly, horribly upset. I wish I could say that I didn’t tell her it was her fault, but I probably did. She was as upset and inconsolable as I was. I do remember that, although I think I was the one officially blamed. The setting and the setup were so far out of proportion to the actual consequence. And we were both old enough to accurately perceive the real consequence. The actual consequence was truly gut-wrenchingly horrible.

I wish I could tell you properly about that feeling so you never, never feel it. I felt the horrible starvation death of that parakeet in my soul. And no one else was in that feeling. No one could absolve me from it, or console me with it.

There were all these other complicit, accountable, and responsible people around me who had seemed to fail in small and meaningless ways. It was as if they conspired to trap me in this consequence. The temptation was to rage, pass blame, and explain it away. Certainly, my mind gnawed at this problem for years afterward. But facing the outcome directly, it really wasn’t on the table. Over the years, they all dropped out of the story. Because I was the one who had to go on living with the irrevocable consequence. My Indigenous friends say time is testimony. And with time, it clarified.

It was totally, completely between the parakeet and me.

• Black Cat Bone — Laika

What I learned about the ethics of inaction

So I will tell you what I learned.

I learned it doesn’t matter if it’s fair. It doesn’t matter who else is involved and how they set up the story. These things happen in the cracks of society, groups, institutions, and procedures. We’re often just the bystanders, always just a little bit easier not to lift the cover and look inside the cage.

It doesn’t matter what they do.

When I really learned the ethics of inaction, it was between me and me. When I finally got it, doctor training didn’t teach me anything I didn’t already know. Nor can it replace that reckoning.

And I can truly say I learned my lesson.

• Lucky Now — Ryan Adams

How I applied what I learned

This experience changed a lot of things about my life.

I’ve always been into wild animals in adulthood. My personal conclusion was that the cage itself was wrong. The parakeet would have fed itself if it hadn’t been in a cage. I prefer wild animals and take a lot of joy in watching wild birds. I don’t believe in exotic pets or animal trafficking. The entire supply chain that put the parakeet in the cage in our house, I decided I didn’t want to invest in.

I work a lot on biodiversity; we do ecotourism at Savimbo so people can see birds in the wild with guides. Which is a cooler way to meet foreign and exotic birds.

I worked as a doctor, firefighter, and paramedic. High-tech CEO now and lots of international development. This training and experience refined my feelings on this topic and gave me practice making ethical decisions in scenarios of uncertainty.

I have a panel of people I consult and trust who also have experience and rely a lot on feedback for different scenarios. Lately, that includes a lot of Indigenous elders and shamans, which is an extra dimension of deliberation I really enjoy. Their leadership training is different but very rich.

I pick up the odd human rights case; this month I’m at the UN Human Rights Commission for a rough mining case that came across my desk last year. I learned various reporting and enforcement protocols; there is a system for this kind of shit ‚ — when it’s bigger than a parakeet.

I work a lot in climate, where ethics of inaction get a lot of people because nature and the planet are a real area of tough collective inaction. Mark Carney and his speech at Lloyd’s in 2015 was a great summary of this with a real effect. I like the work of PIK Potsdam Climate Institute on that. It’s clear, informative, and action-oriented. Empowering stuff.

But I’m telling you this story and how it affected me for a reason.

I hope you will learn from my story. So you never have to learn the ethics of inaction the hard way. You can learn from experience, or you can learn from love. And sometimes when you see high-functioning people, it's easy to misunderstand the cost they paid for that function.

So I’m sharing my real story, not the Trendsetter one, out of love.

• Love at the Five and Dime — Hart Rouge

The parakeet story was originally published in Quirimaeus on Medium, where people are continuing the conversation by highlighting and responding to this story.

The terse report was he had assaulted someone at his school. He was unstable, possibly injured, broken glass on scene. He would be placed in the padded room — we might need to use the Haldol.

“Be careful,” my mentor told me. “Get the nurse to show you the panic button, make sure you keep your distance during the assessment. I’m very busy, I’ll get to it as soon as I can, but it could be a while.” Psych cases often languished in busy Canadian ERs because they were triaged as less life-threatening than breathing difficulties or major traumas.

My attending of the day was a grizzled veteran of the pediatric hospital. Famous for something or another, with neat iron-grey hair and emerald scrubs that matched her eyes. Everyone bowed and scraped but I saw a kindred immediately and gave her a cheeky grin, which she grudgingly returned. I’d won her over early with some crisp, clean, assessments. Now, having proven my value, she was using me to lighten her workload. A true compliment from a staffer.

“Will do,” I said heading off immediately with a secret curiosity. I hadn’t worked with dangerous teens before.

I made friends with the appropriately burly psych nurse and entered the room cautiously.

The room was empty except for an industrial tan pleather couch with two occupants and a TV bolted too high on the wall to reach. The tableau was comically exaggerated. On the couch nearest me was the school principal, a middle-aged man with a portly belly and a carefully nondescript short-sleeved shirt. His arms were folded over his injured pride as he stared at the wall in grim masculine resolution, studiously ignoring his companion.

On the other side of the couch was my juvenile offender. Somehow unselfconsciously arrayed in mimicry of the exact same posture. Crossed arms and jutting jaw he also stared at the blank white wall in sullen silence. His legs stuck straight out from the couch, barely reaching the edge. A tiny child of no more than six years with the black spiky hair of an Indigenous youth.

I took one look at the two of them, their mirrored disgust. No reconciliations were forthcoming here.

“I’m separating the two of you,” I said with a crisp authority I really had no right to assume. I was only a visiting medical student, on my first pediatric emergency rotation. But they didn’t know that.

I asked the nurse to turn the television on for the boy and the principal followed me out, relieved to be able to recount his tale. Once ensconced in an interview room he waxed eloquent. The boy was violent, aggressive, and shouldn’t be in his school. He displayed a red mark on his arm, perhaps a small bruise, did we treat adults as well? He had been injured!

First, his duty, for the institutional record. I should take this down. Children ‘like that’ didn’t belong in the affluent and trendy neighborhood on the north end of the city, surely everyone knew. The boy should be attending school in the impoverished east-side suburb where he would be more comfortable.

The subtext was clear even to me, visiting from another city. The lower-income school had more Indigenous resources? I inquired casually…

Of course they did. They took care of foster children, and… problems. Well, they had security at least. The boy had assaulted him! The principal! All he had done was try to sit him down in the chair and the child had bitten him! Bitten him and hid under the desk. He was clearly violent. He needed to be medicated, probably… sedated, perhaps… something. Something was definitely needed.

The boy had arms the size of matchsticks I thought, while I estimated the principal was at least 250 pounds.

I remembered my mentor and her reputation held in my hands, my assumed mantle of authority, and studiously did not laugh.

Instead, I projected a cloud of sympathy. I’d learned I got better histories if people thought I agreed with them and back then I didn’t see any ethical dilemmas with it. We were both professionals, no? I just needed the facts, I’m sure we can help, I murmured, in my best soothing tone.

And the facts were these. Somehow simultaneously telling two different stories to the two of us. The story pouring from his lips evoked nearly opposite responses in my heart and his.

The boy had been raised in a closet back East. His stepfather had beat him often. But the authorities kept returning him to his mother, despite significant substance use, perhaps prostitution. Because he was raised in a closet he had never learned to speak. (“Children who can’t speak shouldn’t be at our school…”) Eventually, the stepfather had kicked the boy’s ribs through his liver, and because he nearly bled to death in the hospital ICU he had been sent to this city finally, to live with his father. His father had been trying to retrieve him, unsuccessfully, for several years.

I was unsurprised at this. I knew much about Aboriginal rights from three years working on an Indigenous wildfire crew. Twenty men, from twenty different reserves across the province, and all the stories of their wives, daughters, grandmothers, and institutionalized children woven in the air around the fire at night. An oral history of anguish and dispossession, and the living evidence of continued stewardship of the land.

A brotherhood that was somehow flexible enough to include me in its embered embrace.

The boy’s father was probably just unable to advocate for himself in the white man’s system like so many Indigenous parents of his generation. Now, unexpectedly a single-parent household he was working on a large construction project in the wealthy part of town, so the boy had been enrolled in the nearby school mid-year.

The wealthy school run by the man in front of me. (“I tried, I really did, I wanted to help…”) But the boy didn’t understand a word anyone was saying to him. He couldn’t speak at all. There were speech therapists, but the wait-list was too long. (“What are we supposed to do with him in the meantime I ask you…”) Indignation. Frustration. Spread hands.

So today’s story unfolded. His first week this. The boy hadn’t sat still in class, didn’t understand the teacher, and had been sent to the principal’s office. But when the principal tried to place him in the chair, grabbing both his arms firmly, the boy had erupted. (“He broke my photographs! The window! He bit me! And screamed! He is uncontrolled with rage!”)

Now the man in front of me shook with outrage — perhaps adrenaline. He must protect himself. His staff. His office. Surely this boy was someone else’s problem. Now it would be seen to. It had been documented!

Yes, I saw, he was my problem.

This boy was now my problem.

That’s the problem with being psychic. You see things sometimes and you know. Because you see them they are yours. And I saw the boy’s past clearly. So he was my problem.

His probable future was grim.

All of history and the system, his father’s poverty, the angry principal, his culture’s colonization with white-man’s addictions and white-man’s gangs, his own neurology and trauma… all arrayed against him at this point. A tiny scarred child in a web too massive for him to perhaps ever comprehend.

But I saw it. Psi unfolds in the mind like that, an aerial pattern, views across lifetimes, cultures, archetypes, the path souls tread.

Fate is a spider woman, weaving a delicate pattern. But she can be outmaneuvered.

“It sounds like the problem is he can’t speak,” I said hacking at the nearest strand of the web. We would start with the proper naming of things. The problem was not the boy himself.

Hesitation. “Well… yes.” Agreed the principal cautiously, “That’s part of it.”

“Do you think he thought you were going to hit him when you grabbed him?” I asked hacking at the next. “Seeing as how the last time a man grabbed him he almost died?”

“I would never!”

“Of course not. But do you think he might have panicked?”

“Well, he can’t do that again.”

“Of course not. So a speech therapist then?”

“You’ll never get it approved. They have a waitlist a mile long. It’s at least nine months.”

“But if I did?”

“If you did. I would consider it.” the man was suddenly somewhat mollified. Musing. Perhaps he wasn’t the hero of the story as he’d thought. I pressed the thought into his mind telepathically. A suggestion. Perhaps he was the ogre… Did he really want to be an ogre? Or did he want to be a champion?

A pause. Some surprise… his, not mine. We were still on the same team, but the goal had somehow unexpectedly shifted.

“Okay. Let me see what I can do for you.” I said, as though it had been his plan, then left the room, my task clear.

Now the boy. Would he join us?

The boy was my Helen Keller. I saw with the sight that doesn’t see. Before the water. Before the understanding. Locked in a world of screaming. A closed system.

Consent is everything in my world, in the apriori world I inhabit, before I inhabit a body, or the role of a medical student. It’s a free-will world, and my superpowers are constrained by your freedom. The boys as well. The principal and my mentor. I can only cut the strands of the web that I am allowed to.

The boy might be small, but he was alive, he must also agree.

How did I speak to a child who can’t speak? Could the child even be reached?

Some feral children are never reachable. The psychology textbooks are discouraging. Too much isolation, too much trauma, at the wrong developmental years, and human brains never develop properly. The wrong stimulus. They are forever cognitively bound, cannot be trusted. Must be institutionalized.

I saw the problem, but was there actually a solution?

I went back to the room. The nurse had turned the television to a hockey game. The boy was rapt. Riveted. Good, he could pay attention to something. I went into the room, but he didn’t even look at me. Refused to look away from the screen. No interaction whatsoever.

Hmmm. I remembered this from my childhood. Growing up off the grid we didn’t have television. When we went to our friend’s houses to play, we were truly hypnotized by the moving pictures — far more than our peers. Babysat by screens from a young age they could dip into and out of the digital streams, but for us, it was a cognitive tar-pit. One stray gaze and we were glued. Our friends said we wanted to watch the TV more than play with them — and they were right.

He acted like he hadn’t seen a TV before.

But I also sensed he didn’t trust me. He was huddled on the couch and I caught him watching me carefully from my peripheral vision. I reached out and read his emotions. He was still very consciously angry, indignant from the day. And I was looming over him with a clipboard.

But it wasn’t just his conscious mood that was the problem. His subconscious was much older than a child’s. A silent rage emanated around his baby body. Very red. Very old, growing in the dark in the closet over the years. Reinforced with hunger and terror. Defensive walls of molten metal.

I was the enemy, and he had an already-developed warrior’s soul.

I sat on the floor and tried waiting for his attention but he didn’t falter. Fifteen minutes is a long time for a child of that age to do anything, but he sat as still as a baby fawn in the grass. Curled and silent.

Suddenly inspiration struck. I stood and left.

Back in the pit, the central command station the nurses swarmed over a trauma in the bay. Tubes and IVs. My mentor’s jewel tones were easy to spot, she stood straight and petite barking commands in a deceptively calm voice. She was a serene as the bleeding child on the table in front of her, and the flat-lined monitor overhead. Meantime her junior colleagues and my scurrying peers manned the other eight exam rooms, and the TV overhead showed a croup-season waiting room list a mile long. My boy wasn’t even on the radar and the last thing my mentor needed was for me to investigate a bunch of croup cases to add to her caseload. I was safe to pursue my own illogical path.

I scoured the desks irritating the veteran medical receptionist. Finally, I had my prize, two plastic cups, a black felt-tipped marker, and a blank piece of paper.

Returning to the relative solace of the observation room I dropped my clipboard on the floor and started cutting the paper by folding it, soaking it in spit, and tearing it into rectangular strips. The boy’s stoicism began to crack as I ignored him. He craned his skinny neck.

I made a very small, spit-soaked disc, and colored it carefully black. Then I made two artfully folded hockey sticks and gave them racing stripes. The boy’s eyes gleamed. I felt his attention on the psi channel. He was watching me now, and only pretending to watch the TV.

Then I began to score petite, paper goals against myself into the plastic cups, winning by a mile. After establishing my clear dominance, I was definitely winning, with no goalie to defend the plastic cup. Finally, I looked up, and off-handedly offered the boy a hockey stick.

His future was suspended in the air in front of him, in the form of a slender paper hook, trailing gold dust to my second sight. (Sometimes I do that if I’m doing something important.)

He made eye contact for the first time. And took the stick with alacrity. I had myself a game. The iron door in his psyche opened.

I had initiated the war games properly. He would engage.

We spent the next twenty minutes in a hot and furious tourney. I lost badly. I was delighted. He began spewing war cries on the psi channel the first time I scored a goal. When I shouted back silently, he looked up in surprise. We spoke the same language.

I looked at him with surprise as well. I hadn’t thought his intellect was developed. But his intellect was fine. His silent thoughts were incisive, observant, and fully conversant.

Sometimes this happens. Children with no verbal capacity can be quite fluent telepathically, but with no one to listen or respond they don’t know they are broadcasting. They think it’s a private channel until your thoughts join theirs in happy communion. Like two velveteen puppies in a play fight.

This child was astonishingly bright. Psychic, not just driven onto the channel from trauma and isolation. He began playing happily. Then we exchanged a smile at a missed goal. And then instantly, love. A golden, electric current shot between us.

It’s hard to describe what that means, and in this context, it will seem too easy. Too instant. Like magic.

But it is.

Real love is magic. Instant and permanent. Spit, paper, a plastic cup, then… a lifetime, the universe. He trusted me now, he couldn’t not. But everyone trusts love. It’s an open conduit.

I had expected to score a goal or two, perhaps get a read on his mind. But now I unexpectedly held his fragile, hidden, traumatized, child’s heart in my hands. Fluttering with its four delicate valves, beating butterfly wings against my mind.

That’s the hard part. Love gives you an infinitely valuable gift in an instant. And then you must bear it forever, always, a conduit to someone’s innermost being that can never be exploited or fucked up. Because you can hurt them so much more than anyone else.

Better to be an enemy, than beloved and harmful. I had opened a door I could not close.

I had his consent. The only consent that mattered. He could love, would love if someone could reach him.

Now, my battle. The real one. I retrieved the nurse and taught him how to play paper hockey. The boy let me, cautiously trusting my telepathic recommendation of a better tournament. The nurse did not disappoint, he proved surprisingly flexible toward child incarceration. (I think he was also a hockey fan and there was no game outside the room.) I left them on the floor, the nurse’s large ass and the child’s bony one raised in the air as they knelt over their respective cups.

I found my mentor. She was sitting with her feet up on my chair looking exhausted. “I hope you have a report for me,” she said.

I gave a succinct history, stating the history of extreme physical abuse, the likelihood that the child had misinterpreted the principal's actions as threatening, and my observation that the child had normal intelligence but needed speech therapy.

“I think the principal would be amenable to him returning to the school with some extra funding. Can you get him a special-needs classification? A speech therapist?” I asked.

My mentor gave me a steely assessing gaze. “I can,” she said reservedly. “I can pull some strings. You get me a physical exam?”

“I wanted your permission,” I said. “Can he leave the room?”

“You can try,” she said. “But if he freaks out he goes back in the room. If he can sit still for an assessment I’ll make the call.”

I returned to the room. My charge looked up. “He’s winning.” the nurse said ruefully. I brandished cookies and water. My charge stood up, happy to see me. I showed him the door. He obediently walked out, took the food, and followed me down the hall. He trailed crumbs with miniature slapping delinquent feet.

I showed him the table and he climbed up expertly. I looked at him and he looked at me. Touch was going to be a problem. I remember an ex-boyfriend of mine who had been severely beaten in childhood. He could hardly bear to be touched — never by surprise. I was worried the boy would react violently again if I touched him.

I reached for my stethoscope. Put it on, and listened to my own heart. It beat with a steady thump. He watched me, chewing quietly. I cleaned the earpieces with an alcohol wipe. Then handed him the earphones. He listened carefully. Looking at me quizzically. I took the end from my heart and put it on his shirt. He heard his own heart and looked at me in surprise. A sudden grin flashed across his face. I gently took the earpiece back and listened to the precise thah-thump under his skinny ribs.

After that it was easy. He played with the stethoscope and let me remove his shirt for a well-child exam. Slender white scars crisscrossed his body. Little brown cigarette burns, and some jutting ribs where they had been broken. An oddly angled long bone or two. Small scars on his head. His diminutive frame was a Frankenstein map of abuse.

The heartbreaking aspect of working with abused children is how carefree they can be. They really don’t know any better. The boy was more interested in the cookies I handed him formally as we completed each stage of the exam, and using the stethoscope to listen to my lungs the way I had listened to his, than he was in his own old injuries or my nearness.

Exam completed I took him back to the nurse. He was transformed, obedient and interactive. Even a bit friendly. I was sure this wasn’t the end of his behavioral journey, but he would present well to the child psychiatric team when they arrived. My charge was going to be his own best witness now.

I found my mentor. “The child was perfectly compliant and nondisruptive and exactly mimicked the pulmonary exam on me after I performed it.,” I said. “He’s obviously quite bright and observant, see for yourself. I suspect his behavioral problems are partly due to frustration with the inability to communicate. Perhaps even giftedness…”

I didn’t know if that was exactly true, but gifted kids are known for having behavioral problems and the kid had enough labels to last a lifetime. Might as well throw a wrench into the works and make them rule out intelligence, with some carefully worded clinical notes. I didn’t mind evening the scales with some undeserved praise.

My mentor spent the obligatory fifteen minutes with my charge required by law. She carried enough clout to decide his future with a tersely-worded sentence to her colleague, but the child-psychiatrist would be the one determining care.

I hovered anxiously in the background, projecting patience when the hellfire began to light in the boy’s eyes again. “Pleeeease trust her,” I asked him on the psi channel, and he reluctantly did.

She was brisk, incisive, and thorough. Also a bit surprised.

“He does seem quite intelligent she said. And I can’t see any obvious misbehavior… Those scars are awful. I’ve seen it before though.” her eyes were swiftly sympathetic toward me. Most med students don’t handle severe child abuse well. I didn’t say anything and she went on.

“This is a complex case you know, it won’t be as simple as an ER assessment. He needs a whole team.”

“But you can jump the queue.” I said ”For the team? For speech therapy?”

“I can get him into an expedited program,” she admitted. “The ER has a fast track. We don’t use it often, it’s only valuable because it’s not used all the time…” Then looking at my hopeful face.
“Fine, fine. I’ll make the call. It doesn’t fix everything but you’ve convinced me. It’s clear you’re passionate about this.”

It was. I was.

Love always goes both ways.

On the way out of the hospital at the end of the shift, I stopped by to say goodbye. The boy’s father had arrived.

He was younger than me. A slender man. Quiet. A little hopeless, the weight of the world newly hung on his slender shoulders. I read his thoughts. It was hard for Aboriginal men to get good construction jobs, he had been fighting his own battles to get on the well-funded government project he was working on. Long hours, the junior man working harder than everyone else, microaggressions. Then a sudden child, a bewildering grade school, white-people paperwork — not easy. He was overwhelmed, sleepless nights filled with worry for the traumatized boy who arrived cut into jigsaw pieces. A family system skeletonized from urbanized Indigenous translocation, addictions, and ancestral trauma. Crowded housing.

I saw that he had showered after work and before coming to the ER. I felt a surge of tenderness. It was something my old crewmembers would do, cleaning up for the white doctors. So they treated you better. He wore a plaid shirt, new jeans, and clean leather workboots with new laces. He looked up with silent trepidation.

I saw that the boy and he really didn’t know each other that well yet, they had only recently met after all. They sat together on the couch. But this time the boy was on his end, looking up at him starstruck. The boy was clearly capable of bonding after all. I was not the only one with a newly-opened door to his butterfly heart. The man looked at me expectantly, emanating nonverbal respect, alert, needing to know about this child, his son.

Stories matter. They are everything sometimes.

“The doctor will be in soon to speak with you directly,” I said. “She is my boss. She will arrange things, people to help you….”

I paused, choosing my words carefully. Venturing past strict empiricism for the sake of the boy, the rewritten story. “I think your son just got confused at school today. Lots of new people, a strange setting. I don’t think he meant to cause trouble. He just needs some teachers who understand him better, he can definitely learn to talk with some patience. He’s very bright. I’m glad I met him. I think he is smarter than anyone knows and he has normal emotions for a child his age. ..Also, he’s also very good at hockey.” I smiled, the boy smiled back shyly, ducking his head.

His father looked relieved. I was holding a clipboard. I was a white doctor, and I thought his son was smart. The white people saw his son the way he did. We agreed with him. The boy was special. He gently clasped his child’s leg in reassurance. The boy snuggled under his arm and he hugged the child to his side. A cloud of silent love erupted from him, dark velvet gold, enveloping the boy. All that the child would ever need. A bubble on the end of the couch, in the empty room. The two of them sheltered from the world.

He nodded at me and they looked up at the screen again. Two dark heads with spiky hair watching the game in silent companionship. That was the last I saw of them.

Hearts and hockey sticks can be arranged, folded. Spit, a tear, a crease in the right place, and some racing stripes.

It just takes a bit of creativity and some Magic.

Hearts & hockey sticks was originally published in Quirimaeus on Medium, where people are continuing the conversation by highlighting and responding to this story.

I was in my first year of a general surgery residency, but not even that, a preliminary year.

My colleagues, compatriots, and comrades were international. Some of them had been in practice for over 12 years in countries where you’re a clinician before you’re a doctor. They were so experienced and I was just… a baby doctor I said, I’m a baby doctor, my senior resident might have a different plan, let’s get you started and I’ll review with them. I always said that because I was, and I hate misrepresenting my abilities.

They need to know, patients need to know who to listen to, and especially when there is a hierarchy of doctors. They need to know who is the boss doctor. And that everyone is working together in a team.

But this boy came in, maybe a man. He was a young black man and I just… it’s not the same. I worked in gang intervention, and I worked with convict crews and ex-convicts for many years in my first career fighting wildland fire. I lived in southern Georgia, my friends are black men in the Marine core, my boyfriend at the time was a black ER doctor, and I started a post-incarcerated program at my high-tech consulting company with a black activist from Oakland for social justice. A good aim, a good ideal. Something we all want. We really do. We want to connect, and to stop being angry.

It’s tough to say anything as a white woman, but I think I can say, it’s not the same. You have to care enough to make sure that the person in front of you is getting equal treatment, and equity means sometimes scraping the blinders off your own eyes.

So this boy, he just had an ingrown hair, and it had become infected, and then he needed an abscess drained. A simple surgery but they hadn’t done a good job with the wound they had been sloppy and hadn’t made sure all the bleeding was stopped before they closed the wound. And he was bleeding, that night after the surgery, and it just didn’t stop. And the ER doc tried, and I’m sure they really did down there, in the pit we called it. He told me he did and I believed him. But they couldn’t stop it. And I was called, and I tried. I tried really hard and I couldn’t stop it.

And you’re not supposed to call the senior resident. You’re supposed to hold pressure for 20 minutes, hard, and not call. And then do it again, and again and eventually it will stop. That’s what they say. And I did. 20 long minutes with this man. Who wondered why his surgery was causing bleeding and had no other medical problems, who was a college student, and just needed to stop bleeding after a simple surgery. And I saw him there, naked black butt in a sea of white towels, blood everywhere. Spotted on the sheets and on his clothes and on the towels and the bed, and by then it was also on me.

And I looked at him, and he looked at me. And I saw all the gunshot victims who had died in Chicago last year and I thought, this is wrong. This isn’t Chicago. This man is somehow getting mistaken for someone else.

And I thought, fuck it. He is not in a shootout in downtown Chicago, he is a man thousands of miles away, who had a simple surgery, and doesn’t deserve to spend his evening in the ER begging for a simple solution. He is getting the wrong treatment. He needs a better doctor than me. And I called the senior resident on call. She was furious. She yelled at me over the phone. And I stood my ground and I insisted she come in to the hospital. I tried I said, and the ER doc tried, and he’s still bleeding. She said you didn’t try, you can’t call me for every little thing.

You didn’t try. You need to try again she said. And I said, no, you did this operation, you need to come into the hospital and help me because I don’t know what to do and I am concerned about him. And he has bled enough. And she did.

Her anger was so hot, when she arrived. She spoke to me like a subhuman, when she arrived in the middle of the emergency room in front of all the doctors and the nurses where my patient couldn’t hear. And everyone looked at their screens and their notes and pretended they didn’t hear what a bad doctor I was. But I heard it. And it hurt.

And she went into the room and thank god she stopped the bleeding. She was crisp, and kind, and cool and she stopped it under 20 minutes. She just knew more than me, and she had a lot of tricks I had never seen and they worked. And my patient was better. He stopped bleeding. He went home. And I was so relieved, so relieved. I wanted to cry with gratitude that he was taken care of.

I hope he doesn’t remember. I hope he forgot me, and that night, and how long it took. But I remember. I remember how he was treated, and that he wasn’t supposed to be important enough to wake a senior resident in the night time. And I have to remember because six months the senior resident waited until she gave me a damning enough review to make sure I would not practice medicine again. It was not the only thing I did that pissed her off, and it was not the only reason I chose to leave, but it was the real reason she never forgave me. Because I woke her up that night and insisted that she take care of her patient. I knew it when I did it, that it was going to be bad.

Sometimes you have to choose, who you want to be. And I chose. And that was love. I loved that man. I still do. And I would do it again.

You don’t have to know someone to love them.

Nightbleed was originally published in Quirimaeus on Medium, where people are continuing the conversation by highlighting and responding to this story.

Perhaps it is my story too. I saw myself so clearly reflected in you, the stubborn set of your shoulders, your bustling energy, exploding sense of right and wrong. Stalwart fierceness and shining intelligence.

And once, when you raged in a tantrum, then shuddered into wracking sobs, and fell into an awkward hug. Then came back days later, shuffling your feet, uncertain, and asked me shyly if I would clasp you again like that. Like a weighted blanket.

It felt good, you explained. I don’t think you knew why. But by then I did.

I had held you like a straitjacket until your emotions broke. No one had ever contained you like that before, so you could experience the full brunt safely and feel the release after they peaked. You missed your developmental tantrums at two. You were busy surviving.

You were pretty tough at that time. I think you were eight. Big enough to be too big. Honestly, you kind of needed a straitjacket. I know kids shouldn’t, but you were still on several psychiatric medications, your dad secretly double-dosing you with them randomly when he felt like it to turn you off. My first experience with that kind of child abuse. I’m so sorry. I stopped it when I figured it out. And I mean I really stopped it. But we hadn’t sorted it out yet.

But we did, and this story is why.

So, how to tell this story? I am telling it so one day you can find it and see yourself reflected like a jewel in my eyes. Without telling too much — telling what’s not mine to tell.

I came for all kinds of complex adult reasons of my own. But all you probably knew, and what is probably the truth, is that I came like Mary Poppins on an umbrella.

And I came for you.

They didn’t tell me anything, of course. I learned later that you had hit the former nanny in the head with a rock, and she had to go to the hospital. But given the adults I found around you, I kind of support that. Most adults wouldn’t, but you did what you had to.

You were fighting your own child’s guerrilla war.

So this day on the beach, our first day. All I had to go on were vaguely worded warnings that you could be tough. (I had been hired off an online listing, which was very irresponsible of all adults involved, including me.) But all boys are tough, and I was tough, and I needed the placement. So I took the job, and the first day, you were bundled into my car with your brother and various beach stuff, and we went to the beach.

The adults weren’t going to warn me, but they sort of tried. Some vague hints about “behavioral problems” and that you shouldn’t travel in cars. But I was the nanny, and didn’t listen any better than you did. I had been in the frozen winters of the far north for too long. So we were going to the beach and we did.

Later on, I saw you and your brother unbuckle and rage around the car, try to jerk the steering wheel from your dad on the freeway. Really dangerous stuff. But that was with your dad, and you had your reasons.

But they didn’t tell me that then. It was our second day. They just sent us off in the car. No warning. And there you were, sitting next to me, buckled up reluctantly. Clearly ready to explode with impatience. But you and I negotiated a deal for car gum, and for the music, and you liked New York by Jay Z, and I did too, so that was that.

And I looked over at you to the right of me, and it suddenly occurred to me, and I said in startled realization — because you were tapping the windowsill, and looking at the sea, and immersed in the song — “There is nothing wrong with you!!” I saw so clearly in that moment that you were a totally normal kid. And you looked at me, your gaze direct. And I think you realized for the first time in your incredibly short life that it was absolutely true.

And that was that.

But the beach. This story is about the beach. It’s about the beginning. Because we broke you out of your prison. And maybe now, if you read this as an adult, you still wonder what happened. Maybe you won’t forgive me for abandoning you. And there are all kinds of adult reasons why I had to. But there are all kinds of adult things I did when I left that changed your life forever too. And I will tell you here, in our public private, and then maybe you will know that I didn’t abandon you at all.

But I want you to know why I didn’t abandon you. Why I fought for you with all of my adult-power.

It was the crab.

We went to the beach. And you and your brother went wild. You ran and ran. You rolled in the sand. You ran into the waves, you just flew across the sandy water, and you were covered in sand from head to toe. Your sandy blond hair was sandy sandy. And you were wild with the sun and the freedom, and I just watched.

Too much time in the house? I thought. I had no idea.

I will briefly sketch your history, which I learned later, so it makes more sense. But there was a mansion, and an addicted mother, and her addicted friends. And years and years of early childhood abuse. Them high with you and your brother, and sexual abuse because she didn’t protect you. And no one to see, no one to care, and movies no child should see playing over and over in the background. And finally, they put her away.

But for you, the damage was done. You were ‘damaged’ and your dad saw it as a continual honeypot for rotating foreign nannies, and the other kind of abuse started, or maybe continued. More sophisticated medical and emotional abuse with twisted disciplines. The medicated, standardized, pathologized, doctor-teacher enabled abuse and labeling.

The endless suffering of a psychologically traumatized child “victim” who can never be anything else.

So in the car, when I said, “There is nothing wrong with you.” It might have been the first time an adult ever said that to you. But I could see in your defiant gaze in that moment that it was something you already just knew.

You were so bright, so brilliant. Even then.

So on the beach, when I finally let you out. Out-out with the sun and the sand and the endless ocean you ranranranranranran. And I didn’t know why, but I just let you run. Boys need to run, I thought. Good for ‘em.

But that wasn’t the moment that mattered. The moment that mattered came later. It was when it was time to go. You weren’t very good with any kind of discipline then. It unlocked the anger and the uncontrolled will that had been so bent and twisted by authority figures.

And it came down to the crab.

You had been collecting hermit crabs. Running in zig zags and throwing them into the water, and you had one in a blue bucket. And you wanted it. Crabs aren’t that… conscious. You wanted to take it home, and I said, “No.” And you began to shake. You weren’t very tall, only came up to my waist. But it was a real shaking. An adult shaking. Your eyes narrowed, and I saw real adult compressed fury.

“It’s mine,” you said. “If I can’t take it home, I will crush it. I will kill it. I caught it and it's mine.”

And there it was, some eyestalks waving, totally confused in a blue bucket sloshing around in some seawater and sand. And I looked at it, and I could tell by then that it was going to be a long, tough ride home. I could see you weren’t responding like a normal kid to normal things. I didn’t see the full picture then; it took a few months to map it and untangle the psychology web you’d been snarled into. But I could see that day that I had to pick my battles, and I was sorely tempted.

I can kill a crab. I’ve killed crabs. It’s a crab. There are thousands of them. There were thousands of them at our feet right then. I mean, it was a good specimen, you had selected well — I was impressed with your hunting abilities. But I thought, is it really worth this dumbass crab? Am I really going to pick this battle?

It was my first day on the job. I wasn’t sure if it was worth it. There were all kinds of adult reasons why it wasn’t worth pissing you off — yet. I knew we were going to have it out — I just wanted to pick the place and time. Not with an uncontrolled and unpredictable child who was still practically a stranger on a public beach.

And I looked at the crab, and I looked at you, and I thought, no, we are going to have this fight right now.

“That is not your crab. That crab belongs to itself,” I said. “It lives in the ocean.”

And I looked at you and I really, really meant it.

And you lost it. I mean, you were really great at losing it back then. You had taken the standard of “disturbed child” and constructed a monument to it. You were smart as hell, and the adults had only given you one way to succeed. So you were quite the fireworks show.

It was impressive.

But I noted, because I am the oldest of nine children, that you never once dropped the plastic bucket.

So I stood there as stubborn as you were — are. A will like ours can’t be tamed. Yours hadn’t been broken, and mine never will either.

And I waited.

And when you calmed down. I said, “That crab belongs to itself, just like you belong to yourself. You don’t own the crab, and I don’t own you.”

And that plunked you like an arrow in the solar plexus. You stood there dumbstruck, and you looked at me, and I looked at you.

And you put the crab carefully on the beach. And we left, and we made it home. (Thank god for Jay Z.) And after that, we had a real alliance.

And we did the work. It took about three months. But you did it. We did it. Because we had an agreement.

You belonged to yourself.

I know your life changed after I left. I heard from others that you were doing better. There were all kinds of adult reasons I had to leave. But I didn’t leave you without protection. I put the guardrails in place. I marched you over to the best neighbor, and I had a real talk with him. And I made him promise, adult-to-adult, if you needed shelter, you could go there, no questions asked. I made sure the authorities and people around you knew what was happening. I talked to your teachers. I told your doctor that you had changed, and he was grateful. He said he knew you just needed ‘behavioral interventions,’ and he couldn’t give them to you. I said I did, and you were better, and he agreed, and he said he would stop medicating you. And from what I heard, it worked.

But I want to tell you what we know. You didn’t need behavioral interventions. You needed love.

You needed real,

blistering,

hardcore,

LOVE.

And you got it from me. And that was ALL you needed.

And now, when I work on the environment, I think about that. I think about all the broken little boys in the world and their stupid crabs in buckets. And I tell them all the same thing.

There is nothing wrong with you. And it is not your crab.

The goddamn crab belongs to itself.

Boys and buckets was originally published in Quirimaeus on Medium, where people are continuing the conversation by highlighting and responding to this story.

Depression is best understood within the larger context of human mood (or emotional) regulation, as a specific pathology of the homeostatic process. To define depression, we must first exclude low mood in a healthy individual.

What depression is not

In the healthy human body, mood varies from day to day, and from moment to moment within a range, similar to other homeostatic processes in the body (Carstensen et al., 2000). According to Beck’s cognitive model, which has persisted for 50 years, a healthy individual’s mood responds to subjective cognitive interpretation of external or internal experiences. Internal mood deflects “down” to a sad mood in response to an experience the individual interprets as negative, and “up” to happy mood in response to an experience the individual interprets as positive. The “magnitude” of the deflection is influenced by the degree of positivity, or negativity the individual assigns to the experience (see Figure 1). (Beck, 1974; Beck and Haigh, 2014).

Now, for the first time in human history, we can measure objective evidence for this theory by mapping emotional variation in the human brain using functional MRI (Ochsner et al., 2002).

An important facet of healthy emotional regulation is the return to baseline mood after the stimulus has passed. As Brickman demonstrated in his study of paraplegics and lottery winners, individuals return to their baseline level of happiness after a stimulus, regardless of whether it is positive or negative (Brickman et al., 1978). However, the length of time it takes to reestablish equilibrium may depend on the magnitude of the stimulus (see Figure 1). (Chen et al., 2013; Parker, 2013)

Current evidence in the field of positive psychology suggests that although personality and choice are factors in the establishment of a “contentment with life” baseline for mood, this baseline is not entirely subjective. In accordance with Maslow’s hierarchy of needs model, evidence suggests that a minimum level of basic human needs must be satisfied in order to achieve contentment (ie a “good-enough environment”), after which individual variation in interpretation of stimulus becomes a significant determining factor in baseline mood (Maslow, 1943; Veenhoven, 1991; Cloninger et al., 2006; Drakopoulos and Grimani, 2013).

When defining depression, it is essential to differentiate between low mood due to grief, low mood due to past or current trauma, and low mood due to a pathology of homeostatic mood regulation. (O’Donnell et al., 2004; Association and Psychiatric, 2013; Parker, 2013; Gambrill, 2014)

Grief is defined here as: low mood due to an experience that a healthy individual interprets as severely negative (e.g. losing a limb, losing a loved one, being diagnosed with a terminal disease, or experiencing a rape).

Grief may take a significantly longer period of time to return to baseline mood due to the magnitude of the stimulus. Grief is an inescapable facet of human existence, and the healthy individual follows a natural process of recovery from such an event, which includes low mood for at least two months by DSM-V definitions (see Figure 2). (Association and Psychiatric, 2013; Larson, 2014)

Trauma is defined here as: low mood due a recurring series of experiences which a healthy individual interprets as severely negative, (e.g. living in a concentration camp, being a victim of domestic abuse, experiencing childhood sexual abuse.

Trauma may take a significantly longer period of time to return to baseline mood due to the duration of the stimulus. Trauma is a severely disruptive experience. The healthy individual survives a traumatic situation by adopting a specific set of mental coping mechanisms (often described as “stoicism”), which can be maladaptive when the stimulus is removed (Peterson and Seligman, 1983; Frankl, 1985; Herman, 2015). Thus, low mood due to past trauma may require an alternate treatment approach (O’Donnell et al., 2004) including therapy for post-traumatic stress disorder.

It is also important to recognize that individuals seeking treatment for low mood may be living with past “hidden grief”, or current “hidden trauma” which is unrecognized in the prevailing culture. These are health disparities that may be compounded by the pathologization of low mood in a healthy individual (Braveman et al., 2000; Parker, 2013; Gambrill, 2014).

Examples of hidden grief include stillbirth and miscarriage (Turner, 1989; Scott, 2011); caregivers of loved ones with dementia (Dempsey and Baago, 1998), adoption, and other forms of disenfranchisement (Kamerman and Doka, 1991)

Examples of unrecognized trauma include intergenerational trauma (Cole, 2006; Gorman, 2010); living with prejudice or discrimination (Cox et al., 2012) living with a non-visible mental disability or giftedness (Beljan et al., 2006; Arnold and Fisch, 2011), and being transgender (“Unable to find information for 7716660,” n.d.)

Low mood may also be a symptom of many other disorders including substance use (e.g. ecstasy), recreational or prescribed medication (e.g. Accutane, estrogens, statins, etc.), and disease in other areas of the body (e.g. Alzheimer’s disease, hypothyroidism), brain injury (Jeffrey S. Kreutzer, Ronald T. Seel, 2001; American Psychiatric Association, 2013).

In addition, low mood is a co-occurring symptom in many mental conditions including bipolar disorder, ADHD, PTSD, and schizophrenia (Bleich et al., 1997). As any professional working with depression can attest — it remains difficult to differentiate low mood from recurring trauma versus underlying pathology (O’Donnell et al., 2004).

What depression is

There are many diseases that affect different regulatory mechanisms in mood homeostasis. However, depression as a disease is best conceptualized as an inability to return to baseline mood after a negative stimulus.

At the neurochemical, biological, emotional and behavioral levels, depression can best be described as an “inability to recover” (see Figure 4) (Kramer, 2006; Brosh, 2013).

Although any negative stimuli may produce depression in a susceptible individual, severely negative stimuli (such as grief or trauma) are more likely to produce depression in those who have difficulty recovering. Thus past grief, and past trauma, as negative stimuli, may result in depression but are not equivalent to it.

In addition, current hidden grief and trauma in maintaining low mood may mimic symptoms of depression. (O’Donnell et al., 2004; Yehuda et al., 2006), If depression persists, it can also include anhedonia, or the inability to benefit from a positive stimulus.

To conceptualize depression as a chronic disease it is helpful to use the model of heart disease. Depressive symptoms can be compared to high blood pressure (many patients suffer from depression for many years before seeking treatment and the symptoms are often not visible). Suicide attempts can be likened to angina, or non-fatal heart attacks, (indicators of worsening disease). Fatal suicides are the mortality measure, for the end-point of untreated or unresolved depression (Kessler et al., 2003; Richards, 2011).

Within this context, suicide prevention is a tertiary preventive care measure for depression, treatment of depression to prevent suicide is a secondary preventative care measure, and prevention of the onset of depression is a primary preventative treatment for depression (Rose, 2001).

Primary prevention for depression is underresearched and under-deployed, primarily because of significant financial interests in the treatment of the pathology. (Fani Marvasti and Stafford, 2012)

How to prevent depression

While there are venture capital firms who propose the entire US population adopt prophylactic antidepressant therapy (see aforementioned industry), we advocate for non-medical interventions for coping with what will likely be for all of us a grief, trauma, and low-mood-ridden life.

Currently, there are three main primary treatments for depression, each targeting a specific point in the development of depression. They are as follows (see Figure 5):

1. Modulating individual interpretation of unavoidable negative events as they arise, thus reducing the magnitude of a negative stimulus with techniques such as cognitive behavioral therapy (CBT) and logotherapy (Burns, 1981; Frankl, 1985; Robinson and Sirard, 2005; Goodkind et al., 2011; Ameli and Dattilio, 2013; Wexler, 2014).
2. Enhancing the ability to recover from negative stimuli by developing and fostering resilience and grit and by facilitating emotional processing (Teasdale, 1999; Yehuda et al., 2006; Duckworth and Quinn, 2009; Kleiman et al., 2013; Wright et al., 2013).
3. Increasing the intensity of positive stimuli as they arise with techniques such as learned optimism and gratitude (Reker, 1997; Desrosiers and Miller, 2007; Seligman, 2011) .

Written by Drea Burbank, MD. This article is adapted from a whitepaper produced for Stanford Health4All Science of Prevention course, March 17, 2014. Collaborators included Dr. Maile Jachowski and Nicole Jeffrey.

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How can we prevent depression? was originally published in Quirimaeus on Medium, where people are continuing the conversation by highlighting and responding to this story.

I looked down at him, our first meeting. His aura was black, indicating the premeditated murder of a human. Guess they hadn’t caught him for that one. His gang tats were Latin American and his eyes were psi-black, indicating he didn’t like me at all.

I wasn’t fussed, he couldn’t do much about it, paralyzed from the neck down.

“It’s not going to work,” I told him. His lip sheened with a fine perspiration, cheeks pink. He was mid-thirties, although his body was atrophying and softening with immobility.

His second try with this method. I admired his doggedness. I would do the same in his shoes… well socks I noted. Shoes weren’t going to be necessary for him ever again.

“You’re just going to have a fever, and be miserable, and then get better anyway. You are too healthy. No judgment, but you might as well let me treat it.” He snapped something irremediably foul about my genitalia in Spanish. “Hablo Espanol,” I said. “Yo se,” he said.

An impasse.

We looked at each other, grudging respect. I used to work gang intervention in LA. This wasn’t California, but we understood each other perfectly nonetheless. Just because someone is paralyzed, doesn’t mean they are nice. In the prison wing of our hospital, I hadn’t expected nice. Or reasonable. Now he seemed curious, I wasn’t the normal white girl-doctor. I wasn’t going to cut him any slack.

“Okay,” I said. “I’ll be back tomorrow.”

His chart said he’d been in the unit for months. In the general population, he would be prey for the other inmates, so he stayed in limbo at the hospital, but it wasn’t a quad ward. The nursing staff had no specialty training and there was no rehab medicine. The TV bolted overhead was his only entertainment, changing the channel wasn’t an option.

It was hell I thought. This was literal hell on earth.

I returned the next day. A perfunctory exam, aside from the fever his clinical status hadn’t changed in months.

“How long have you been in the bed?” I asked.

“What’s it to you? he demanded. He was irritable, the infection was exactly as I predicted.

“If I had to lie here without moving I would be suicidal too,” I said. He held my gaze, my honesty unexpected.

“Eight months,” he said.

“What would make you want to live?” I asked.

He looked away from me. “I just want to go outside and feel the sun,” he muttered softly, unexpectedly. “Or listen to music, I used to like the radio.” Then grudgingly, “I’ll take the antibiotics.”

I doubted he had been that candid in years. In unsafe environments, you never disclose true desires, people just use them to hurt you. I knew that from childhood — I suspected he did too.

Exiting by the guard station I investigated. The main prison allowed daily yard walks and prisoners had a commissary that sold radios. But the hospital ward lacked these amenities. He hadn’t been convicted so he couldn’t be transferred to the state inmate quadriplegic ward.

The guard was a young Chicano man. Perky, intelligent, and active. “Don’t let him con you,” he warned. “That said, it’s a bad case, he’s here indefinitely and it’s a miserable existence.”

I trotted to the attending in the trauma bay. A young man from an urban center back East, New York, or perhaps Boston. The smartest surgeon on our team, he’d moved here for the politics. He propped pointy cowboy boots on the desk. “Let him rot,” he said. “He killed a cop.”

“He allegedly killed a police dog when the SWAT team broke into his house unexpectedly, in return, they shot him eight times,” I said. “He hasn’t been convicted of any offense yet.”

“A police dog is still a cop and did more for society than that drug dealer,” he snapped. “You’re a bleeding heart Californian aren’t you?”

I didn’t tell him what people from Idaho said about dude-ranch cowboys wearing shiny boots. “It doesn’t matter where I’m from,” I said, “What matters is that this man is physically incarcerated by his injuries more than he could ever be legally imprisoned. We couldn’t strap a healthy man to a bed for eight months with no intellectual stimulation even with a conviction, what gives us the right to do so by inaction?”

“Why don’t you fix it,” he said. “I don’t want to hear about it.”

“Thank you.” I said, “I will.”

Easier said than done. I spent precious hours of leisure time navigating the prison system. Arguing for the human rights of an inmate who didn’t like me (or my genitalia) much. Months after the rotation ended, I wrote impassioned letters about human-rights abuses, the need for quadriplegics to access art and nature therapy, and how if we can’t do it in Guantanamo, we shouldn’t be able to do it in Texas.

White girl I might be, but white girls are good at one thing, even if they are from Idaho: writing bleeding-heart letters.

I saw the prisoner again before I left — the residency, medicine (it was a tough year). There was a cheap grey radio taped to the side of his bed. Tinny mariachi music wailed on the hot summer air. The TV was off and his face was beatific. Other senses can be heightened in quadriplegics. He just nodded at me stone-faced. I couldn’t stop smiling.

“He goes outside once a week now.” The guard reported. “Honestly, we like it too, we don’t get much fresh air here either.” He hesitated, this slim man, a mirror of my patient if things, choices, had gone differently. “You know, you can’t judge anyone here… when you do this job.” He said carefully, with a direct gaze. “The doctors don’t always understand. But the inmates are all just humans, it doesn’t matter how they got here.”

Compassion can be surprising — who has it, who doesn’t.

Originally published at https://www.kevinmd.com on February 8th, 2022. Reprinted with permission.

A radio was originally published in Quirimaeus on Medium, where people are continuing the conversation by highlighting and responding to this story.

She thinks she knows everything but she’s missing basic, fundamental pieces of the puzzle which makes her overly stupid for how smart she is.

She gets the chance to talk to Jesus so she goes camping with him. And she goes to an abandoned building near the campsite and sings all her questions, in what is an undeniably operatic rendition of what she thinks she wants to know but what is also self-serving, like overly dramatic and staged.

And there is Jesus right beside her. And he hears her but she doesn’t ask him direct.

So she learns three things, later, afterward, once she’s normalized to the tribal ways and the ways of the woods and the basic politnesses of things. Because she was citified, and basically deaf, and stupid, didn’t know stuff. Senses numbed. So overly offensive but also forgiven in the way that stupid tourists are basically forgiven for being offensive and stupid. (Lots of stupid in that paragraph.)

She learns that he heard her loud and clear the whole time. And nothing was private, nothing was in an overly-staged song in the woods.

Because the woods are quiet, and everyone can hear everything and she’s just city-loud in the woods so he heard her in the woods the whole time. Because its air and sound travels in air, so don’t even have to be Jesus to hear that kind of shit.

And she learns he’s Jesus so he heard her thoughts the whole time too. Because she was right next to him thinking about it so that’s also pretty obvious but she doesn’t even believe in that yet. So it takes a while to believe someone would be right next to you knowing everything you are thinking but not letting on.

And she learns that he saw more and heard her secret intentions to publish a juicy story, and be so important publishing it, and her childlike narcissistic ambitions about being famous and a writer about Jesus, and also her naivete about things because the song was well produced but basically Superstar material. Overly fantasized about things and stuff.

So that was what I dreamed and it’s true.

But I still don’t know how to ask the question to the Jesus sitting beside me. I’m still singing songs in the woods I guess.

Only now I kind of know about it a bit.

I guess I will learn stuff now, so I’d rather be a stupid woman singing in the woods, and learn stuff, than not get invited to go camping with Jesus at all.

Camping in the woods was originally published in Quirimaeus on Medium, where people are continuing the conversation by highlighting and responding to this story.

Luckily for you, Q&A with the universe is a divine right. No one can take it away from you, and you can use it to directly circumvent all intermediaries, and save money in the spiritual marketplace!

This is a basic article about getting your first experience of a question-answer cycle, I have an advanced article on the same topic.

Be patient toward all that is unsolved in your heart and try to love the questions themselves, like locked rooms and like books that are written in a very foreign tongue. Do not now seek the answers, which cannot be given you because you would not be able to live them. And the point is, to live everything. Live the questions now. Perhaps you will then gradually, without noticing it, live along some distant day into the answer.

— Rainer Maria Rilke, Letters to a Young Poet

The spiritual journey is often described as a mountain, with many paths up the mountain. I’ve also used the metaphor of a spiral but you guessed it, its a 3D spiral! That goes up (or down — depending on my mood and how much I’m bitching).

So… you got to do all your own hiking. Some paths are more direct, and some are more circuitous and most people get pretty tired on the journey, etc, etc. You get the metaphor.

The reason I use this metaphor here, is the most important thing you got in the entire world to get up that mountain is the ability to ask a spiritual question, and get a spiritual answer. And it’s yours it’s always with you. You get a sense of up and down, and you get an inborn map and compass.

Even though you still have to get up the same elevation as everyone else, you can figure out your own direction. And with a little bit of practice you can navigate the mountain much, much easier and pick easier routes rather than harder ones or maybe just routes that are better suited to you. It’s your journey after all. Why shouldn’t you control it?

Questions and answers for skeptics

Luckily most skeptics are going to be intimately familiar with the concept of hypothesis, and experimental data, theories, etc. Hopefully my readers are a bit more advanced on these topics and understand empiricism, and love the scientific method as much as I do.

I think navigating the mountain for most people in the West starts with questions formulated as hypothesis about their birth religion, science, atheism, etc. And people get their answers from embodied sources and personal experience long before they consciously realize they can upgrade the question/answer circuit.

Pretty much everyone I know has kind of muddled around with finding their own belief system. But most people get really mired in the belief systems and guilt trips of their parents, and societies. Sometimes they progress to rebelling against those belief systems but that is still strongly parentally influenced belief. Eventually some intrepid adventurers make it out of conditioned or reactive cognitive patterns to more structured decision-making about the nature of the world, their personal morality, and what happens after death. (Incidentally this is why I generally like atheists, they are usually in the third stage.

All this stuff is better coupled with action so people are aligned but its all pretty humdrum and doesn’t really challenge the status quo human condition.

I want to take you to another model, and if you’re a skeptic I hope you’ve read up on model-dependent realism so you can at least consider this possibility.

I want to introduce the hypothesis that infinite consciousness actively answers any question you formulate. And I want you to test it in your own life.

Questions and answers in spiritual awakening

Most spiritual awakenings start with a question. It’s usually a real question, and it’s usually put to the universe, the divine, or a higher power (in other words not your tennis shoes or your aunt Maime.)

The question is usually pretty simple. For me it was almost verbatim:

“ I’m really happy and successful right now, but something is still missing. I’m not complaining, because I’ve got everything I think I could want. I just want to know is this all there is? “ .

I asked the stars. There was this lake I used to go to at night to look at the stars and I asked the stars. I didn’t even believe in a God at the time. I just needed to talk to something that felt… open and not closed. So I asked something I perceived of as infinite at a time when I really did perceive of myself as having everything I wanted (money, relationship, status, beauty, etc.) and if you had known me then you would have agreed — it was a pretty good year for me.

And I forgot all about my little slip of the mind until the earth caved in on me a couple months later. I lost everything in such a specific and abrupt way that I was mortally offended with the divine. I was raging at God less than 6 months later (yeah by then I was mad at a real being) and I was reminded gently that I had specifically asked to know, and now I did.

Now I am glad I lost everything. Now I know how paltry what I had at the time was. Now I am so grateful I asked that question and was not satisfied with what I thought I had. But the point I’m trying to make is not whether spiritual awakenings are worth it, the point I’m making is it was a true question.

If you ask a true question, you will always get a true answer. The problem for most people who feel cut off from the divine lies in one of two things:

1. They do not ask a true question
2. They do not recognize their answers.

Let’s talk about those two things really quickly.

A true question

• A true question must be open. You must actually realize you don’t know. You have no fucking clue. It’s got to be a cognitively available area. This means you have removed previous beliefs (often through disillusionment) and are temporarily open to receiving an answer.
• A true question must be addressed to the right place. You’ve got to ask Source, God, the universe, something bigger than yourself. If you’re an atheist you can ask the void that you sense. It’s critical that you step beyond traditional sources for the answer. If you ask your cousin Joe, or the internet, or your professor, or your religion you’re not actually opening up at all. You have to ask something that is unexplored to get something new.
• Good: It’s also important that you ask something good, think high not low. So something loving, beneficial, and interested in your wellness as it coexists with that of other peoples wellness.
• Smart: There is infinite intelligence in infinite consciousness. Generally people think the cosmos has the intelligence of a very large chunk of granite, or is uninterested in them. It’s not, it’s really fucking smart, it knows everything about you, and it’s already trying to talk to you. So ask something you think is smart.
• Open: Ask something that is going to listen to your input. This might sound silly but the universe really, really cares what you truly think. It might have a much better idea on how to get what you want, but it does care what you want. And it cares what you see so ask something open to dialoging with you. Start a conversation.
• A true question must be consistent. If you want an important answer, you have to be consistent, and persistent. So ask in all ways; mentally, physically, and emotionally. Ask again, and again. Write it down, put it on your mirror ask verbally, in prayer, and with some heart. Keep in mind that false beliefs about answers can block you from getting them clearly so be patient if it doesn’t come right away. Be inquisitive about the question itself, if its not quite right then work on it and make sure its really reasonable.
• A true question must be logical. Don’t ask the universe “Why am I a bag of shit?” because you’re not. The universe can’t answer that because it’s not logical. You’re not a bag of shit so no answer is possible. It’s a nonsense question. Don’t ask nonsense questions. If you’re not getting an answer make sure its not a nonsense question.

Recognizing answers

• A true answer can’t hurt you. If you’re a truly, subconsciously afraid of an answer, you’re not going to get it until you’re open to it. Most people are subconsciously afraid of God, so asking if there is a God can take a long time to get an answer. Try asking for simple, practical shit to begin with: “How do I fix my credit score?”, “Why is Cousin Jack irritated today?”, “How do I wake up on time in the morning?” stuff thats pragmatic and measurable.
• A true answer builds a relationship. This is a relationship you’re building with the universe. One where you trust your ability to ask questions and get answers. Answers that are beneficial to you, helpful to you, and pragmatic. No problem is too small or two big. So start small, and simple just like you would with any other relationship. Track your performance. Build trust, listen, apply what you get, come back with more questions. This is your right. You can take time to test the waters. Its okay to be vulnerable and protective of yourself at the same time.
• A true answer is personal. You’re an infinitely complex and unique being. Nothing basic about you. The universe knows this, an answer is going to be specific to you in the place and time you need it. It’s going to seem very, very individual. It’s very common for it to be related to unique personal history that only you would really understand. This is your channel, its going to come with your name on it in one form or another. In your language, culture, history, and emotional frequency.
• A true answer might take a while. Don’t be surprised if your first real answer takes months. And don’t be a dipshit and put a question out there, then forget you asked it. Then be all like “the universe doesn’t’ answer me”. Pay attention to what you are consciously, and subconsciously asking for, keep a list, and refer to your list occasionally to see if your question got answered and how it got answered. I keep a running list of important questions at all times.
• A true answer can come from anywhere. If you ask a question today, and your best friend walks up tomorrow and answers it, that still counts. The universe gets credit. The universe can use strangers, friends and family, the radio, or your own suddenly burning desire to march down to the nearest library. Don’t fuss about how, fuss about what. Focus on getting the question right, and your head might spin about how fast and efficiently it gets answered.

The point is not to earn a PhD in getting one question answered. The point is to get ALL your questions answered. All the time. Continually. From the highest source, without intermediaries.

I fully admit I recently asked the universe if I was a free-climber (can never fall) or a ski jumper (epic crash and get back up again). After a week my friend texted me a picture of a mountain goat on a cliff and said “They just walk like that, also no fear”. I was delighted and satisfied. It was a good question, and a lovely answer. The universe is just really fucking smart and I’m always so goddamn grateful I made friends with it.

Next question.

Questions and answers conclusion

This ones a bit long, and I’m glad because if you only get one thing from reading my content, you have the one thing you need. It’s more important than anything that you can get information from the divine directly. It is the core skill you need to optimize your life, and start really living it.

You don’t need me or anyone else on this path. You get this straight and you can safely “kill the Buddah”.

My best wishes on this. I am never so satisfied as when a student returns to me and tells me they got a real answer to a real question for the first time. Teaching them how to do that is my only real job .

On questions and answers was originally published in Quirimaeus on Medium, where people are continuing the conversation by highlighting and responding to this story.

This year, the US Congress is considering regulating one of the most lucrative and powerful companies in the US because teenage girls are attempting suicide over algorithmic images of female bodies.

As an MD-technologist, this is my jam. For over 10 years I’ve been obsessed with how technology makes us sick, and how it can be used to make us healthy. So what can we learn from these events, and more importantly what should we do differently?

“Nowadays, women not only feel pressured to bodily compete with socially generated beauty standards, but to compete with their own image too — in some ways the image offers the only way to attain the unattainable beauty standards. Yet, through this, women are merely perpetuating this skewed perception of what female corporeality ‘should’ look like”.

— Isabelle Coy-Dibley, “Digitized Dysmorphia” of the female body, Nature

How Instagram makes teenage girls sick

As we learned from tobacco control, when a for-profit industry creates a disease, the only effective public health intervention is regulation, followed by anti-industry advertising.

Yep, unquestionably, Instagram isn’t good for teenage girls. We even know why, something called negative social comparison where rumination on how oneself underperforms related to others is linked to depression.

This should come as no surprise to anyone who knows anything about depression — some of the most effective therapies for depression in the 21st century involve examination and redirection of repeating negative illogical thoughts. We also know from both depression research and behavioral economics that humans are irrational, so it doesn’t matter if the thoughts and social comparison are illogical — the results on mood are the same if the thought is repeated frequently enough.

Last, but certainly not least, there is a for-profit industry behind this dysmorphia. The weight ($189 billion), surgical ($50 billion), beauty ($511 billion), sex ($186 billion), and fashion ($3 trillion) industries all profit from negative social comparison and are incredibly adept at creating it. Instagram takes its cut — with $20 billion in ad revenue in 2019, it comprised more than a quarter of Facebook’s total revenues, outperforming YouTube. Instagram also has the majority of the beauty industry’s advertising, capturing 93% of L’Oreal’s ad spending among others.

So it’s a bit of a no-brainer that thinking badly about our bodies causes depression, that the people who profit from this depression pay Facebook to show us photoshopped images of surgically-enhanced celebrities on Instagram, and that the canaries in our psychological coal mine are girls naive to advertising caught in the throes of hormonal disruption.

In other words, what have we really learned about the human psyche from the Instagram research? And more importantly, what do we need to do differently?

A ray of hope in the digital darkness

It is pointless to argue that teenage girls should stop looking at the female form. We are a visual primate species with assortative mating behavior based on biological markers of fertility and health. Although most Western women find the commercialization of female bodies to be oppressive, our species display our bodies to attract mates, display athletic prowess, and place ourselves in a social hierarchy. Digital representation may be new, but the drive to observe women is age-old.

Furthermore, the freedom to choose how female bodies are displayed is a core aspect of most women’s rights movements. No Western woman would argue that we ought to cover up women, or display their bodies less — celebration of the female form in visual art and fertility is central to our societal values and archetypes and goes back to the stone ages.

Healthy teenage girls have the psychosocial developmental task of creating a personal and sexual identity — they need to explore and try on various personas to see what fits which makes them avid curators of other women’s bodies, histories, and lifestyles. This is both necessary, and healthy. If this exploration is blocked it can lead to dysfunction in later life. We want our young women to explore their bodies and this generation will be doing it via images and video on social media, apps, the internet, and streaming sites.

No, instead I posit something different: We don’t need to stop looking at women’s bodies, we need to start looking more closely at functional women’s bodies.

There is a critical note in the Wall Street Journal report that has largely gone underappreciated in the debate about regulating social media. As Al Jazeera reports:

“While other apps such as TikTok, a short-video app, are grounded in performance, Instagram focuses on the body and lifestyle. The pressure to look perfect and have an ideal way of life could send teens spiralling towards eating disorders and depression, internal research found.”

TikTok is better than Instagram. Performance is better than body and lifestyle. This is not only brilliant, but it’s also a way forward. Let’s unpack it.

Performance and function in the female form

“Look at how lovely Mary is. Look at the lovely dress she’s wearing. Look at how lovely her demeanor is. Isn’t she getting chubby?” The attention is placed on her being not her doing. Which means that she gets that hit of belonging — whether it’s positive or negative — when she is being seen when her attention is turned inwards on herself. Billy is rewarded when his attention is out. Mary is rewarded when her attention is in.

— Kasia Urbaniak, Women, Men, and Power

When we look at great works of art, Michelangelo’s sculptures and sketches in the 1500s or Rodin’s Kiss in 1888 the male forms haven’t changed much — they could still grace the cover of a Men’s Health magazine. But the female forms are dramatically different from the images we currently see in Women’s Health and markedly less muscular.

We don’t need to stop looking at women’s bodies, we need to start looking more closely at functional women’s bodies.

‘ Digital dysmorphia ‘ is a term coined for the dissatisfaction women feel about their bodies, in association with their ability to digitally edit representations of themselves. We should also note that these representations bear little resemblance to functional anatomy or musculoskeletal development which has been evolutionarily conserved throughout 200,000 years of our species development. In some ways, we are becoming dissatisfied with health itself.

As more and more women in public life turn to surgical enhancement to meet a mythical female geometry, I wonder, do we really even have the faintest societal grasp on what functional female bodies actually look like?

Have we allowed men armed with Photoshop, leading advertising agencies, and equipped with scalpels to reach into our very bones to define us yet again? Have women edited themselves into oblivion in search of self-perfection?

Or are we simply using the wrong metrics to assess ourselves? Is it as simple as replacing still photographs with video? What if we ad in a real-life challenge instead of a lens filter?

Why can’t we use images to make ourselves healthier

“We need to get serious and stop pretending that telling patients to lose weight without giving them the tools to do so is an acceptable intervention.”

— Dr. Elisabeth Poorman, Why I’ve Stopped Telling My Patients To Lose Weight

Yes. I unquestionably chose a woman on the far-slim side of healthy female anatomy for the cover of this article. I wanted you to compare her anatomy with the common images we have all seen gracing the cover of Vogue. I wanted you to see the muscles in her thighs, and her balance and wonder how she developed them. I want you to wonder why you haven’t seen that kind of definition often before.

Obesity is one of the leading health crises of the modern world described by the World Health Organization as “one of today’s most blatantly visible — yet most neglected — public health problems”. Obesity is responsible for around 280,000 deaths annually in the US alone and doctors are often at a loss as to how to treat or prevent it. In a 2015 UK study of 99,791 obese women, the annual probability of returning to normal weight was 1 in 210, 1 in 677 for the morbidly obese.

We haven’t even begun to solve this problem, but that doesn’t mean we shouldn’t try. I propose that we need to get creative, we need to start thinking outside of the box, and for both our mental and our physical health we need to stop thinking of women’s bodies as an all-or-nothing event.

Women are not static architected images, we are open weather systems, whirling dervishes, and chaotic change.

It might be improbable, but for most women, it is possible to lose fat and get healthy. Women who engage in high-intensity training, follow intermittent fasting regimens, and introduce plant-based diets do reduce their body fat and improve their metabolisms. Skeletal muscle can burn fat in insulin-independent pathways, and increasing skeletal muscle helps prevent diabetes, treat insulin resistance, and counteract harmful effects of obesity.

Images can motivate us to become more active. When I gained weight and restarted my workout regimen a few years ago, I got depressed by all the fitness magazine images showing women whose bone structure was different from mine. They were healthy but on the far side of thin, for me, they represented unachievable ideals. Fortunately, I’m a huge fan of metacognition and mindfulness, which means I’m just smart enough to tell when I’m being stupid about my weight.

I believe doctors have a responsibility to embody preventive medicine knowledge. If we can’t live healthy lifestyles ourselves, how can we effectively teach our patients about them?

I decided to get creative and experiment with visual motivation. I applied a body of knowledge I had developed over the years as a preventive medicine researcher. We have solutions, cutting-edge research on tiny habits for lifestyle interventions, chaos theory in behavior change, mimicry with mirror neurons, and irrationality in decision-making. Using these solutions I decided to work directly from an emotional level.

I could tell the images in Cosmopolitan, and Shape made me sad, images in Oprah didn’t motivate me, but for some reason the images in Women’s Health and Oxygen made me want to get off the couch and work out.

Women are not static architected images, we are open weather systems, whirling dervishes, and chaotic change.

To motivate myself to reach my best body I bought a bunch of magazines and cut them up. I made a poster of women’s bodies who looked like mine — just a bit fitter. I tried my best to match my own ethnicity, age, height, and attributes like shoulders and calves. I also picked women who were only a couple grades more fit than I was (even if my end goal was to be much fitter. I put the images on my wall, in my workout binder, and on my computer screensaver. And I started to work out. A lot. Without having to think about it too much.

It got to the point that whenever I saw this image of Jessica Biel running I would put on my running shoes automatically. And I’d remember the image when I felt like doing a sprint in fartlek. I noticed I felt motivated to get in motion and achieve my own version of the divine feminine. It felt good to be motivated by people who were displaying positive traits of femininity. And I felt like I was collaborating with these women, not competing with them.

As a physician, a researcher, a sometime-couch-potato, and an athlete I can absolutely attest that watching active, functional female bodies has motivated me to lose weight, improve my health status, and reduce my familial predisposition to diabetes.

It has also changed my relationship to my body and that of other women. I feel more grateful for my ability to move, I feel more companionship with other women as they move, and I feel less pressure to conform to artificial female beauty standards as I root my feelings about my body in what it does, not how it looks.

Do it yourself:

If you’re reading this article, and you identify as female I’d like you to try this quickly, watch one or more of these videos, and see how you feel about moving your body:

Now get out there and move your body.

The form of functional female bodies was originally published in Quirimaeus on Medium, where people are continuing the conversation by highlighting and responding to this story.

Dr. Eric Topol wrote an excellent op-ed in the New Yorker titled Why Doctors Should Organize. I’m going to spell out exactly how they should organize.

I spent a year as a UCSF postdoc with the leaked tobacco documents. And this article is taken directly from the tobacco-control playbook. In The Tobacco Wars, we learned that: when a disease is caused by a for-profit industry, the only successful approach is regulation first, followed by treatment.

Doctors should form a nationwide class-action lawsuit against the major EHR companies for cognitive repetitive-strain injury. They can easily prove lost wages and mental strain from technical debt in the software interfaces they are being forced to use. They should demand first-and-foremost that the interfaces are opened to the free market (like an iPhone allows apps to run over its back-end). Any secondary damages gained should be used to form MD-technologist programs at every major medical training site. I’ll explain exactly why, and how below.

Yes, I fully admit I’m no Topol. (My spirit animal is a burdensome pigeon named Eagle.) But perhaps an eyes-wide cyberpunk is the voice doctors need these days. I’m steeped in technology, I’ve been forming this concept for years, and I truly think doctors deserve better than they are getting.

Most of my readers are clinicians and technologists, so I’m going to skim over the current state of medtech and clinical practice. We all know it’s a war zone and the statistics are gory: 1 in 5 doctors plans to leave their current practice within 2 years, doctors have a higher suicide rate than post-combat troops in the US military, doctors make less than high-school teachers, and physician burnout is at an all-time high. (I’m focusing on doctors here but #ilovenurses too, just substitute your specialty if you’re a clinician).

This article was written in response to a conversation with a friend who works for a health insurance company. He described to me with precision exactly how the organization algorithmically identified efficient doctors with legitimate claims, drove them out of private practice by systematically and specifically denying their office’s billings, forced them to join a group practice, and then charged them to convert to institutional EHRs — decreasing their total claim volume.

I got mad. And now I’m going to do something about it.

If you’re a clinician, you don’t need to hear more about the problem. Instead, I’m going to offer a very clear solution.

Legislation is the only option

Doctors are fighting technology, this is a losing battle. Instead, they need to take control of it.

As I’ve described, the current state of clinical practice was intentionally created by for-profit entities for financial gain. If you’re a hospital administrator, work at an HMO, or are an institutional software developer, and you’re reading this you know this is absolutely true — because you’ve attended the same meetings that I have.

This isn’t just happening to doctors in private practice. In large hospital systems, they are being treated even worse, managed by computer algorithms, isolated, and individually shamed when they fall short.

For-profit markets that cause disease must be regulated before any solutions can be implemented.

Doctors are great, but the regulation of tobacco was arguably the most significant public-health victories of our century. It was successful for three reasons, which were executed sequentially:

1. Anti-industry advertising,
2. Multistate class action lawsuits followed by regulation,
3. Recycling of subsequent damages and taxes into unbiased research funding.

It’s time for lawyers to help doctors. It doesn’t matter if the public sympathizes with their plight — because they probably won’t. It only matters if they have a legitimate legal claim.

Doctors must organize nationally in the US and Canada under a class action lawsuit against institutional software developers, HMOs, and hospitals. They must demand that institutional software systems open interface development to a free market. If they can successfully claim damages, or institute taxation, they must recycle all monies awarded to fund MD-technologist programs at medical schools and unbiased interface research.

Failing to take organized action will result in the end of the profession. Bedside medicine is under real, and undeniable threat. Currently, 60% of doctors would discourage their children from following in their footsteps. And high-IQ candidates are choosing technology over medicine as a career. Meantime, as I’ve already explained, high-tech is circumventing clinicians while they are distracted by endless popups in software that was never designed by a clinician.

Doctors are not, and will never be, happy with data entry — and they are not, and should not be working for, machines.

But the biggest threat is still relatively obscure to physicians. The biggest threat is that artificially-constricted interfaces will shrink doctors’ work to predefined algorithms — questions and answers that fit into a checkbox. Then institutions can digitize and automate decision trees based on ritualized language that was never representative of a doctor’s actual cognition or skills.

Why we must crack interfaces

I’ll discuss in another article what type of interface would be more representative of a doctor’s work. But alternate interface designs have yet to be proven or tested. The point is not that one would be better than the other, the point is that one software design team will never cover all the various specialties and use-cases that are needed for meaningful clinician-computer cognitive symbiosis. And individual doctors themselves should be the ones to choose their preferred interactions, just like individuals adapt their cell phones with a suite of small apps that work for them.

Working more efficiently means more control over the use of clinical time. Doctors’ most meaningful work should never be automated. We need to carve out time for clinical tasks like tailoring care to the underserved, kinesthetic physical examinations, complex decisions where patients can practice autonomy in illogical ways, solving emergent problems, and listening to a patient.

“My intent wasn’t to save the world as much as to heal myself.” — Abraham Vergese, Cutting for Stone

We know from radiology that AI is a useful tool, a good cognitive aid. But fast-thinking AI cannot replace slow-thinking physician cognition. Properly applied, AI can help us work more efficiently, but it is meant to automate routine thinking not replace structured evaluations; because it only compounds fast-thinking errors. We need doctors to do their real job.

I’ll explain exactly how doctors could successfully regain control of their cognitive environment, and redesign the application of AI to a cognitive duet.

1. Organize, and stop the infighting

Dr. Topol made a clear case for the need to organize. Doctors need to organize nationally on behalf of patients, and on behalf of themselves and other disciplines.

In the US, the profession has been balkanized from without. They face an excess of administrators without clinical insights. And a mass influx of international clinicians who are disempowered to resist, which creates a brain drain from developing nations. And more importantly, it’s been balkanized from within, by infighting and private interests. Trainees and older clinicians are paying the highest price.

The main barrier to physicians’ efforts to organize is that they typically organize on behalf of legal third-parties — their patients. Organizing to regulate EHRs offers a clear gain, there is a direct financial case for for-profit entities causing damages to doctors themselves.

A national organization that successfully regulates EHR will be taken seriously for apolitical action on behalf of patients.

Now wouldn’t that be nice?

2. Refine the financial case

In order for a class action to be successful, the direct costs to individual doctors from poorly designed EHRs must be clear.

Lawyers study successful class actions like the 1998 forty-six-state Master Settlement Agreement against seven major tobacco companies, or 2019 twenty-three-state opioid settlement against Purdue pharmacy. These cases were successful because they formed strength in numbers, had a clear target, established economic damages, and attracted top litigation firms.

It is not hard to make a case against EHR software. Cognitive repetitive strain injury (RSI) is a novel concept, but there is research emerging that it could be directly tied to decreased motor performance, threat-monitoring depression, and decision fatigue. Clinicians could also just use the physical RSI research regarding the musculoskeletal damages of roughly 4,000 clicks per shift. But it’s probably simplest to use the hundreds of studies documenting the increased 6 hours-per-shift they work on repetitive data entry.

There is simply no excuse for the interfaces clinicians are being forced to use. EHR companies began with a 20% profit margin, airlines operate at 13%, while hospitals operate at 8%. It’s not even expensive for EHR companies to fix the problem. Google is well-known for performing A/B usability testing on the millions of users who use their software. Their results on the ideal button size, items per page, and readable text sizes are publically available on the open-source Material Design site. To quote:

“Material Components are interactive building blocks for creating a user interface, and include a built-in states system to communicate focus, selection, activation, error, hover, press, drag, and disabled states.”

— Google

Poorly designed clinical interfaces have already been robustly associated with errors, bugs, attention diffraction, and increased time. And there is a legal precedent for suing developers for bugs that cause patient harm. But currently, it’s individual doctors that are paying the costs directly out of their time, salary, and health.

Most doctors throw themselves and their families on the institutional pyre to protect their patients from systemic chaos on a daily basis. They are working in an unsafe cognitive construction zone. The increased hours they spend in the EHR labyrinth is a slow death by 1,000 cuts to prevent harm to vulnerable third parties. It’s killing them…

And it has to stop.

For collective action, some individual damages which could be directly tied to poorly designed EHRs include:

• Unpaid time on clerical tasks. Currently, 13% of a clinician’s day is on seeing patients, and doctors are working an additional 10–25 hours per week for free. A legal team would need exact amounts from individual doctors for increased time in a salaried position, decreased billing, and overtime.
• Personal lawsuits for medical errors. Ideally, directly these could be tied to a malfunctioning ERR, but also those occurring at the time of EHR implementation. A legal team would need exact amounts from individual doctors for legal fees, lost employment, and resultant increases in liability coverage.
• Lost wages from early retirement. Doctors are retiring in droves due to EHR avoidance. A legal team would need exact amounts from individual doctors for career loss, retraining, and lost wages.
• Lost wages from depression and burnout. Doctors’ suicide rates and burnout scores have skyrocketed. A legal team would need exact amounts from individual doctors for expenses from counseling, therapy, depression, and suicide prevention.

These numbers are available. And evidence-minded doctors can provide them at an individual level. If they do so in enough numbers they will attract a top litigation team.

3. Pick a target

“The notion that one EHR should talk to another was a key part of the original vision for the HITECH Act, with the government calling for systems to be eventually interoperable. What the framers of that vision didn’t count on were the business incentives working against it.”

— Kaiser Health News, Death by 1000 Clicks

The obvious legal target is national systems, with terrible terrible interfaces, that doctors hate, that have been successfully sued before, and which are creating for-profit market monopolies.

Less-obvious targets include large hospitals that buy EHRs without due diligence, HMOs that force active and escalating administrative tracking by doctors or hospitals for billing, or any medtech company that can be proven to engage in information blocking (actively preventing EHR interoperability to preserve market interests).

Honestly, any high-profile case will do, if it starts backing doctors’ complaints with actual financial damages. Doctors are not being taken seriously, because up till now, although they have been clear, detailed, and even eloquent, they haven’t been talking in the language institutions listen to: regulation, dollar signs, and legal fees.

It’s time to be effective instead. Communication is only valuable if the recipient understands it. Doctors’ abdication of communal legal power does not constitute victimhood.

4. Ask for the right things

Tobacco legislation worked because damages from the initial class-action were not re-absorbed by state budgets. They were put into inviolable funds earmarked only for research into tobacco control.

For a successful class action, doctors must stop looking at the ground they are mired in. They must look at the horizon, and stride confidently toward it. Technology is not going away. It’s time to wrest control of it.

Doctors should demand the following actions:

• Free-market interfaces on any institutional software used by more than one clinical specialty. Just like the Harvard SMART platform and iOS/Android app stores. Then small tech companies have a chance to compete to produce an interface you like, and you can choose that interface on an individual or group basis. Physicians can exercise individual buying power instead of feeling powerless.
• Technologist training programs at every licensed clinical institution with one-year fellowships so clinicians themselves can design these interfaces. There is no excuse for clinicians’ abdication of technology development. (Other than sheer misery, burnout, exhaustion, and heroism. Okay I do get it, I really do.) Physicians can fund their own takeover of medtech, expand their options, and integrate technology the way they did bench research in drug development.
• Interoperability so hospitals can rapidly and seamlessly switch vendors at will. It’s unconscionable that major EHR developers silo patient records which are owned by patients themselves. Even Google was unable to crack this nut. But doctors can free the patient record, and with it themselves.

Future options if physicians took this path seriously could include DAO-administered EHRs, databases, and even hospitals. But let’s start with one clear victory.

It’s time for doctors to take coordinated action on their concerns. And I don’t mean a conference or committee. I mean confidently and precisely enact legal protections for themselves, and their patients. Failure to act will result in disaster.

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Note: There may be affiliate links to the books in this article. You should buy them. They are great.

How doctors should organize was originally published in Quirimaeus on Medium, where people are continuing the conversation by highlighting and responding to this story.